Gastroenteritis

By

Thomas G. Boyce

, MD, MPH, University of North Carolina School of Medicine

Last full review/revision Jun 2019| Content last modified Jun 2019

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Gastroenteritis is inflammation of the lining of the stomach and small and large intestines. Most
cases are infectious, although gastroenteritis may occur after ingestion of drugs and chemical toxins
(eg, metals, plant substances). Acquisition may be foodborne, waterborne, or via person-to-person
spread. In the US, an estimated 1 in 6 people contracts foodborne illness each year. Symptoms
include anorexia, nausea, vomiting, diarrhea, and abdominal discomfort. Diagnosis is clinical or by
stool culture, although polymerase chain reaction testing and immunoassays are increasingly used.
Treatment is symptomatic, although some parasitic and some bacterial infections require specific
anti-infective therapy.

Gastroenteritis is usually uncomfortable but self-limited. Electrolyte and fluid loss is usually little
more than an inconvenience to an otherwise healthy adult but can be grave for people who are very
young (see Dehydration in Children), elderly, or immunocompromised or who have serious
concomitant illnesses. Worldwide, an estimated 1.5 million children die each year from infectious
gastroenteritis; although high, this number represents one half to one quarter of previous mortality.
Improvements in water sanitation in many parts of the world and the appropriate use of oral
rehydration therapy for infants with diarrhea are likely responsible for this decrease.

Etiology

Infectious gastroenteritis may be caused by viruses, bacteria, or parasites. Many specific organisms
are discussed further in the Infectious Diseases section.

Viral gastroenteritis

The viruses most commonly implicated are

  Norovirus

 Rotavirus

Viruses are the most common cause of gastroenteritis in the US. They infect enterocytes in the
villous epithelium of the small bowel. The result is transudation of fluid and electrolytes into the
intestinal lumen; sometimes, malabsorption of carbohydrates worsens symptoms by causing
osmotic diarrhea. Diarrhea is watery. Inflammatory diarrhea (dysentery), with fecal white blood cells
(WBCs) and red blood cells (RBCs) or gross blood, is uncommon. Four categories of viruses cause
most gastroenteritis: norovirus and rotavirus cause the majority of viral gastroenteritis, followed by
astrovirus and enteric adenovirus.

Norovirus infects people of all ages. Since the introduction of rotavirus vaccines, norovirus has
become the most common cause of acute gastroenteritis in the US, including in children. Infections
occur year-round, but 80% occur from November to April. Norovirus is now the principal cause of
sporadic and epidemic viral gastroenteritis in all age groups; however, the peak age is between 6
months and 18 months. Large waterborne and foodborne outbreaks occur. Person-to-person
transmission also occurs because the virus is highly contagious. This virus causes most cases of
gastroenteritis epidemics on cruise ships and in nursing homes. Incubation is 24 to 48 hours.

Rotavirus is the most common cause of sporadic, severe, dehydrating diarrhea in young children
worldwide (peak incidence, 3 to 15 months). Its incidence has decreased by about 80% in the US
since the introduction of routine rotavirus immunization. Rotavirus is highly contagious; most
infections occur by the fecal-oral route. Adults may be infected after close contact with an infected
infant. The illness in adults is generally mild. Incubation is 1 to 3 days. In temperate climates, most
infections occur in the winter. Each year in the US, a wave of rotavirus illness begins in the
Southwest in November and ends in the Northeast in March.

Astrovirus can infect people of all ages but usually infects infants and young children. Infection is
most common in winter. Transmission is by the fecal-oral route. Incubation is 3 to 4 days.

Adenoviruses are the 4th most common cause of childhood viral gastroenteritis. Infections occur
year-round, with a slight increase in summer. Children < 2 years are primarily affected. Transmission
is by the fecal-oral route. Incubation is 3 to 10 days.

In immunocompromised patients, additional viruses (eg, cytomegalovirus, enterovirus) can cause

gastroenteritis.

Bacterial gastroenteritis

The bacteria most commonly implicated are

 Salmonella

 Campylobacter

 Shigella

 Escherichia coli (especially serotype O157:H7)

 Clostridium difficile

Bacterial gastroenteritis is less common than viral. Bacteria cause gastroenteritis by several
mechanisms.
Enterotoxins are produced by certain species (eg, Vibrio cholerae, enterotoxigenic strains of E. coli)
that adhere to intestinal mucosa without invading. These toxins impair intestinal absorption and
cause secretion of electrolytes and water by stimulating adenylate cyclase, resulting in watery
diarrhea. C. difficile produces a similar toxin.

Exotoxins that are ingested in contaminated food are produced by some bacteria (eg,
Staphylococcus aureus, Bacillus cereus, Clostridium perfringens). The exotoxin can cause
gastroenteritis without bacterial infection. These toxins generally cause acute nausea, vomiting, and
diarrhea within 12 hours of ingestion of contaminated food. Symptoms abate within 36 hours.

Mucosal invasion occurs with other bacteria (eg, Shigella, Salmonella, Campylobacter, C. difficile,
some Escherichia coli subtypes) that invade the mucosa of the small bowel or colon and cause
microscopic ulceration, bleeding, exudation of protein-rich fluid, and secretion of electrolytes and
water. The invasive process and its results can occur whether or not the organism produces an
enterotoxin. The resulting diarrhea contains WBCs and RBCs and sometimes gross blood.

Salmonella and Campylobacter are common bacterial causes of diarrheal illness in the US. Both
infections are most frequently acquired through undercooked poultry; unpasteurized milk is also a
possible source. Campylobacter is occasionally transmitted from dogs or cats with diarrhea.
Salmonella can be transmitted by consuming undercooked eggs and by contact with reptiles, birds,
or amphibians. Species of Shigella are also common bacterial causes of diarrhea in the US and are
usually transmitted person to person, although foodborne epidemics occur. Shigella dysenteriae
type 1 (not present in the US) produces Shiga toxin, which can cause hemolytic-uremic syndrome.

Several different subtypes of E. coli cause diarrhea. The epidemiology and clinical manifestations
vary greatly depending on the subtype:

 Enterohemorrhagic E. coli is the most clinically significant subtype in the US. It produces
Shiga toxin, which causes bloody diarrhea (hemorrhagic colitis). Thus, these subtypes are
sometimes termed Shiga toxin–producing E. coli (STEC). E. coli O157:H7 is the most common
strain of this subtype in the US. Undercooked ground beef, unpasteurized milk and juice, and
contaminated water are possible sources. Person-to-person transmission is common in the
day care setting. Outbreaks associated with exposure to water in recreational settings (eg,
pools, lakes, water parks) have also been reported. Hemolytic-uremic syndrome is a serious
complication that develops in 5 to 10% of STEC cases (and 10 to 15% of O157:H7), most
commonly among the young and old.

 Enterotoxigenic E. coli produces two toxins (one similar to cholera toxin) that cause watery
diarrhea. This subtype is the most common cause of traveler’s diarrhea in people visiting the
developing world.

 Enteropathogenic E. coli causes watery diarrhea. Once a common cause of diarrhea

outbreaks in nurseries, this subtype is now rare.

 Enteroinvasive E. coli causes bloody or nonbloody diarrhea, primarily in the developing

world. It is rare in the US.

 Enteroaggregative E. coli causes diarrhea of lesser severity but longer duration than the
other subtypes. As with some of the other subtypes, it is more common in the developing
world and can be a cause of traveler's diarrhea.
Each of these E. coli subtypes can be detected in stool by polymerase chain reaction testing, typically
using a multiplex panel. Sometimes more than one organism is detected simultaneously, the clinical
significance of which is unclear.

In the past, Clostridium difficile infection occurred almost exclusively in hospitalized patients
receiving antibiotics. With the emergence of the hypervirulent NAP1 strain in the US in the late
2000s, many community-associated cases are now occurring. C. difficile is now probably the most
common bacterial cause of diarrhea in the US.

Pearls & Pitfalls

 C. difficile is now probably the most common bacterial cause of diarrhea in the US.

Several other bacteria cause gastroenteritis, but most are uncommon in the US. Yersinia
enterocolitica can cause gastroenteritis or a syndrome that mimics appendicitis. It is transmitted by
undercooked pork, unpasteurized milk, or contaminated water. Several Vibrio species (eg, V.
parahaemolyticus) cause diarrhea after ingestion of undercooked seafood. V. cholerae sometimes
causes severe dehydrating diarrhea in the developing world and is a particular concern after natural
disasters or in refugee camps. Listeria can rarely cause food-borne gastroenteritis but more often
causes bloodstream infection or meningitis in pregnant women, neonates (see Neonatal Listeriosis),
or the elderly. Aeromonas is acquired from swimming in or drinking contaminated fresh or brackish
water. Plesiomonas shigelloides can cause diarrhea in patients who have eaten raw shellfish or
traveled to tropical regions of the developing world.

Parasitic gastroenteritis

The parasites most commonly implicated are

 Giardia

 Cryptosporidium

Certain intestinal parasites, notably Giardia intestinalis (G. lamblia), adhere to or invade the
intestinal mucosa, causing nausea, vomiting, diarrhea, and general malaise. Giardiasis occurs in
every region of the US and throughout the world. The infection can become chronic and cause a
malabsorption syndrome. It is usually acquired via person-to-person transmission (often in day care
centers) or from contaminated water.

Cryptosporidium parvum causes watery diarrhea sometimes accompanied by abdominal cramps,

nausea, and vomiting. In healthy people, the illness is self-limited, lasting about 2 weeks. In
immunocompromised patients, illness may be severe and prolonged, causing substantial electrolyte
and fluid loss. Cryptosporidium is usually acquired through contaminated water. It is not easily killed
by chlorine and is the most common cause of recreational waterborne illness in the US, accounting
for about three fourths of outbreaks.

Other parasites that can cause symptoms similar to those of cryptosporidiosis include Cyclospora
cayetanensis and, in immunocompromised patients, Cystoisospora (Isospora) belli and a collection of
organisms referred to as microsporidia (eg, Enterocytozoon bieneusi, Encephalitozoon intestinalis).
Entamoeba histolytica (see Amebiasis) is a common cause of subacute bloody diarrhea in the
developing world but is rare in the US.

Symptoms and Signs

The character and severity of symptoms of gastroenteritis vary. Generally, onset is sudden, with
anorexia, nausea, vomiting, abdominal cramps, and diarrhea (with or without blood and mucus).
Malaise, myalgias, and prostration may occur. The abdomen may be distended and mildly tender; in
severe cases, muscle guarding may be present. Gas-distended intestinal loops may be palpable.
Hyperactive bowel sounds are present on auscultation even without diarrhea (an important
differential feature from paralytic ileus, in which bowel sounds are absent or decreased). Persistent
vomiting and diarrhea can result in intravascular fluid depletion with hypotension and tachycardia.
In severe cases, shock, with vascular collapse and oliguric renal failure, occurs.

If vomiting is the main cause of fluid loss, metabolic alkalosis with hypochloremia can occur. If
diarrhea is more prominent, metabolic acidosis is more likely. Both vomiting and diarrhea can cause
hypokalemia. Hyponatremia may develop, particularly if hypotonic fluids are used in replacement
therapy.

Viral gastroenteritis

In viral infections, watery diarrhea is the most common symptom; stools rarely contain mucus or
blood.

Rotavirus gastroenteritis in infants and young children may last 5 to 7 days. Vomiting occurs in 90%
of patients, and fever > 39° C (>102.2° F) occurs in about 30%.

Norovirus typically causes acute onset of vomiting, abdominal cramps, and diarrhea, with symptoms
lasting only 1 to 2 days. In children, vomiting is more prominent than diarrhea, whereas in adults,
diarrhea usually predominates. Patients may also have fever, headache, and myalgias.

The hallmark of adenovirus gastroenteritis is diarrhea lasting 1 to 2 weeks. Affected infants and
children may have mild vomiting that typically starts 1 to 2 days after the onset of diarrhea. Low-
grade fever occurs in about 50% of patients. Respiratory symptoms may be present. Symptoms are
generally mild but can last longer than with other viral causes of gastroenteritis.

Astrovirus causes a syndrome similar to mild rotavirus infection.

Bacterial gastroenteritis

Bacteria that cause invasive disease (eg, Shigella, Salmonella) are more likely to result in fever,
prostration, and bloody diarrhea.

E. coli O157:H7 infection usually begins with watery diarrhea for 1 to 2 days, followed by bloody
diarrhea. Fever is absent or low grade.

The spectrum of illness with C. difficile infection ranges from mild abdominal cramps and mucus-
filled diarrhea to severe hemorrhagic colitis and shock.

Bacteria that produce an enterotoxin (eg, S. aureus, B. cereus, C. perfringens) usually cause watery
diarrhea. S. aureus and some strains of B. cereus predominantly cause vomiting.

Parasitic gastroenteritis

Parasitic infections typically cause subacute or chronic diarrhea. Most cause nonbloody diarrhea; an
exception is E. histolytica, which causes amebic dysentery (see Amebiasis). Fatigue and weight loss
are common when diarrhea is persistent.

Diagnosis
  Clinical evaluation

 Stool testing in select cases

Other gastrointestinal disorders that cause similar symptoms (eg, appendicitis, cholecystitis,
ulcerative colitis) must be excluded (see also evaluation of diarrhea).

Findings suggestive of gastroenteritis include copious, watery diarrhea; ingestion of potentially

contaminated food (particularly during a known outbreak), untreated surface water, or a known
gastrointestinal irritant; recent travel; or contact with certain animals or similarly ill people.

E. coli O157:H7–induced diarrhea is notorious for appearing to be a hemorrhagic rather than an

infectious process, manifesting as gastrointestinal bleeding with little or no stool. Hemolytic-uremic
syndrome may follow as evidenced by renal failure and hemolytic anemia.

Recent oral antibiotic use (within 3 months) must raise suspicion for C. difficile infection. However,
about one fourth of patients with community-associated C. difficile infection do not have a history of
recent antibiotic use.

Stool testing

Stool testing is guided by clinical findings and the organisms that are suspected based on patient
history and epidemiologic factors (eg, immunosuppression, exposure to a known outbreak, recent
travel, recent antibiotic use). Cases are typically stratified into

 Acute watery diarrhea

 Subacute or chronic watery diarrhea

 Acute inflammatory diarrhea

Multiplex polymerase chain reaction platforms that can identify causative organisms in each of these
categories are being used more often. However, this testing is expensive, and because the categories
are distinguishable clinically, it is usually more cost-effective to test for specific microorganisms
depending on the type and duration of diarrhea. In addition, polymerase chain reaction testing does
not allow for antibiotic susceptibility testing.

Acute watery diarrhea is probably viral and testing is not indicated unless the diarrhea persists.
Although rotavirus and enteric adenovirus infections can be diagnosed using commercially available
rapid assays that detect viral antigen in the stool, these assays are rarely indicated.

Subacute and chronic watery diarrhea require testing for parasitic causes, typically with microscopic
stool examination for ova and parasites. Fecal antigen tests are available for Giardia, Cryptosporidia,
and Entamoeba histolytica and are more sensitive than microscopic stool examination.

Acute inflammatory diarrhea without gross blood can be recognized by the presence of WBCs on
stool examination. Patients should have stool culture for typical enteric pathogens (eg, Salmonella,
Shigella, Campylobacter, E. coli).

Acute inflammatory diarrhea with gross blood should also prompt testing specifically for E. coli
O157:H7, as should nonbloody diarrhea during a known outbreak. Specific cultures must be
requested because this organism is not detected on standard stool culture media. Alternatively, a
rapid enzyme assay for the detection of Shiga toxin in stool can be done; a positive test indicates
infection with E. coli O157:H7 or one of the other serotypes of enterohemorrhagic E. coli. (NOTE:
Shigella species in the US do not produce Shiga toxin.) However, a rapid enzyme assay is not as
sensitive as culture. Polymerase chain reaction testing is used to detect Shiga toxin in some centers.

Adults with grossly bloody diarrhea should usually have sigmoidoscopy with cultures and biopsy.
Appearance of the colonic mucosa may help diagnose amebic dysentery, shigellosis, and E. coli
O157:H7 infection, although ulcerative colitis may cause similar lesions.

Patients with a history of recent antibiotic use or other risk factors for C. difficile infection (eg,
inflammatory bowel disease, use of proton pump inhibitors) should have a stool assay for C. difficile
toxin, but testing should also be done in patients with significant illness even when these risk factors
are not present because about 25% of cases of C. difficile infection currently occur in people without
identified risk factors. Historically, enzyme immunoassays for toxins A and B were used to diagnose
C. difficile infection. However, nucleic acid amplification tests targeting one of the C. difficile toxin
genes or their regulator have been shown to have higher sensitivity and are now the diagnostic tests
of choice.

General tests

Serum electrolytes, blood urea nitrogen (BUN), and creatinine should be obtained to evaluate
hydration and acid-base status in patients who appear seriously ill. Complete blood count (CBC) is
nonspecific, although eosinophilia may indicate parasitic infection. Renal function tests and CBC
should be done about a week after the start of symptoms in patients with E. coli O157:H7 to detect
early-onset hemolytic-uremic syndrome. It is unclear whether this testing is necessary in patients
with non–E. coli O157:H7 Shiga toxin infection.

Treatment

 Oral or IV rehydration

 Consideration of antidiarrheal agents if C. difficile or E. coli O157:H7 infection is not

suspected

 Antibiotics only in select cases

Supportive treatment is all that is needed for most patients. Bed rest with convenient access to a
toilet or bedpan is desirable. Oral glucose-electrolyte solutions, broth, or bouillon may prevent
dehydration or treat mild dehydration. Even if vomiting, the patient should take frequent small sips
of such fluids; vomiting may abate with volume replacement. For patients with E. coli O157:H7
infection, rehydration with isotonic IV fluids may attenuate the severity of any renal injury should
hemolytic-uremic syndrome develop. Children may become dehydrated more quickly and should be
given an appropriate rehydration solution (several are available commercially—see Oral
Rehydration). Carbonated beverages and sports drinks lack the correct ratio of glucose to sodium
and thus are not appropriate, particularly for children < 5 years. If the child is breastfed,
breastfeeding should continue. If vomiting is protracted or if severe dehydration is prominent, IV
replacement of volume and electrolytes is necessary (see Intravenous Fluid Resuscitation).

When the patient can tolerate fluids without vomiting and the appetite has begun to return, food
may be gradually restarted. There is no demonstrated benefit from restriction to bland food (eg,
cereal, gelatin, bananas, toast). Some patients have temporary lactose intolerance.

Antidiarrheal agents are safe for patients > 2 years with watery diarrhea (as shown by heme-
negative stool). However, antidiarrheals may cause deterioration of patients with C. difficile or E. coli
O157:H7 infection and thus should not be given to any patient with recent antibiotic use or heme-
positive stool, pending specific diagnosis. Effective antidiarrheals include loperamide 4 mg orally
initially, followed by 2 mg orally for each subsequent episode of diarrhea (maximum of 6 doses/day
or 16 mg/day), or diphenoxylate 2.5 to 5 mg 3 times a day or 4 times a day in tablet or liquid form.
For children, loperamide is used. The dose for children 13 to 21 kg is 1 mg after the first loose stool
then 1 mg after each subsequent loose stool (maximum dose is 3 mg/day); for children 21 to 28 kg, 2
mg after the first loose stool then 1 mg after each subsequent loose stool (maximum dose is 4
mg/day); and for children 27 to 43 kg, up to age 12, 2 mg after the first loose stool followed by 1 mg
after each subsequent loose stool (maximum dose is 6 mg/day).

If vomiting is severe and a surgical condition has been excluded, an antiemetic may be beneficial.
Drugs useful in adults include prochlorperazine 5 to 10 mg IV 3 times a day or 4 times a day, or 25
mg rectally 2 times a day and promethazine 12.5 to 25 mg IM 3 times a day or 4 times a day, or 25 to
50 mg rectally 4 times a day. These drugs are usually avoided in children because of lack of
demonstrated efficacy and the high incidence of dystonic reactions. Ondansetron is safe and
effective in decreasing nausea and vomiting in children and in adults, including those with
gastroenteritis, and is available as a standard tablet, oral disintegrating pill, or IV formulation. The
dose for adults is 4 or 8 mg orally or IV 3 times a day. For children, the IV dose is 0.15 or 0.3 mg/kg
(maximum 16 mg) and the oral dose for children 8 to 15 kg is 2 mg, for children > 15 to 30 kg, 4 mg,
and for children > 30 kg, 8 mg. A single dose of ondansetron is usually adequate for children, but if
needed the dose may be repeated every 8 hours for 2 more doses; children still vomiting after 24
hours require reevaluation.

Although probiotics appear to briefly shorten the duration of diarrhea, there is insufficient evidence
that they affect major clinical outcomes (eg, decrease the need for IV hydration and/or
hospitalization) to support their routine use in the treatment or prevention of infectious diarrhea.

Antimicrobials

Empiric antibiotics are generally not recommended except for certain cases of traveler’s diarrhea or
when suspicion of Shigella or Campylobacter infection is high (eg, contact with a known case).
Otherwise, antibiotics should not be given until stool culture results are known, particularly in
children, who have a higher rate of infection with E. coli O157:H7 (antibiotics increase the risk of
Hemolytic-uremic syndrome in patients infected with E. coli O157:H7).

In proven bacterial gastroenteritis, antibiotics are not always required. They do not help with
Salmonella and prolong the duration of shedding in the stool. Exceptions include
immunocompromised patients, neonates, and patients with Salmonella bacteremia. Antibiotics are
also ineffective against toxic gastroenteritis (eg, S. aureus, B. cereus, C. perfringens). Indiscriminate
use of antibiotics fosters the emergence of drug-resistant organisms. However, certain infections do
require antibiotics (see Table: Selected Oral Antibiotics for Infectious Gastroenteritis*).

Initial management of C. difficile colitis involves stopping the causative antibiotic if possible. The
drug of choice to treat C. difficile colitis is oral vancomycin, which is superior to metronidazole.
Unfortunately, recurrences occur in about 20% of patients receiving vancomycin. A newer drug,
fidaxomicin, may have a slightly lower relapse rate but is expensive and is not approved for use in
children. Many centers are using fecal microbial transplantation for patients with multiple
recurrences of C. difficile colitis. This treatment has been shown to be safe and effective in adults
and children (see Clostridioides (formerly, Clostridium) difficile –Induced Diarrhea : Treatment).

For cryptosporidiosis, a 3-day course of nitazoxanide may be helpful in immunocompetent patients.

The dose is 100 mg orally 2 times a day for children 1 to 3 years, 200 mg orally 2 times a day for
children 4 to 11 years, and 500 mg orally 2 times a day for children ≥ 12 years and adults. Giardiasis
is treated with metronidazole or nitazoxanide.

Table

Selected Oral Antibiotics for Infectious Gastroenteritis*

Prevention

Two live-attenuated oral rotavirus vaccines are available that are safe and effective against the
majority of strains responsible for disease. Rotavirus immunization is part of the recommended
infant vaccination schedule (see Table: Recommended Immunization Schedule for Ages 0–6 yr).

Prevention of infection is complicated by the frequency of asymptomatic infection and the ease with
which many agents, particularly viruses, are transmitted from person to person. In general, proper
procedures for handling and preparing food must be followed. Travelers should avoid potentially
contaminated food and drink.

To prevent recreational waterborne infections, people should not swim if they have diarrhea. Infants
and toddlers should have frequent diaper checks and should be changed in a bathroom and not near
the water. Swimmers should avoid swallowing water when they swim.

Infants and other immunocompromised people are particularly predisposed to developing severe
cases of salmonellosis and should not be exposed to reptiles, birds, or amphibians, which commonly
carry Salmonella.

Breastfeeding affords some protection to neonates and infants. Caregivers should wash their hands
thoroughly with soap and water after changing diapers, and diaper-changing areas should be
disinfected with a freshly prepared solution of 1:64 household bleach (¼ cup diluted in 1 gallon of
water). Children with diarrhea should be excluded from child care facilities for the duration of
symptoms. Children infected with enterohemorrhagic E. coli or Shigella should also have two
negative stool tests before readmission to the facility.